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Out-of-pocket expenses (gap cover)
You are here: PrivateHealth.gov.au > Health insurance explained > How insurance works > Out-of-pocket expenses
Your private health insurance may not cover you for the entire cost of a stay in hospital. Before you go to hospital, you and your doctor should discuss the known and possible costs of your treatment, including doctors' fees, accommodation, and other costs. You should also check with your health insurer to find out if you will have to pay a 'gap'.
A 'gap' is the amount you pay out of your own pocket for treatment in hospital, either for medical or hospital charges, over and above what you get back from Medicare or your private health insurer. Some health insurers have gap cover arrangements to insure against some or all of these additional payments.
Hospital gaps
Many hospitals have arrangements with health insurers to fully or partially cover costs relating to hospital accommodation. If you go to a hospital that does not have an agreement with your health insurer, you may face significant out-of-pocket expenses for your treatment. This website has a list of hospitals that have agreements with each health insurer.
If your health insurance policy has an excess or co-payment, you will have to pay the agreed amount of excess or co-payment towards the cost of hospital treatment out of your own pocket, even if your hospital has an agreement with your insurer.
Medical gaps
Health insurers have arrangements in place which may cover some or all of the doctors' fees for your hospital treatment. Unless your health insurer has a gap cover arrangement in place with your doctor that will cover all of your doctor's charge, you may have to contribute towards the doctor's bill out of your own pocket. The Government does not set doctors' fees and the doctor is free to decide on a case-by-case basis whether he or she wishes to use an insurer's gap cover arrangement.
Before you go to hospital, you should ask your doctor for an estimate of their costs. You should also ask your doctor about any other doctors involved in your care (eg anaesthetist, assistant surgeon) and what their charges will be. Check with your health insurer about how much is likely to be covered by your health insurance policy. Your health insurer should also be able to assist with calculating likely out-of-pocket costs.
More information
- A brochure on doctors' bills (PDF 164 KB)
- A brochure on questions to ask before treatment (PDF 2.3 MB)
- The Australian Medical Association has a list of which doctors and specialists are likely to be involved in common surgical procedures: Doctors involved in your care.